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Muñoz-Barrera L, Perez-Sanchez C, Ortega-Castro R, Corrales S, Luque-Tevar M, Cerdó T, Sanchez-Pareja I, Font P, Lopez-Mejías R, Calvo J, Abalos-Aguilera MC, Ruiz-Vilchez D, Segui P, Merlo C, Perez-Venegas J, Ruiz Montesino MD, Rodriguez-Escalera C, Barco CR, Fernandez-Nebro A, Vazque NM, Marenco JL, Montañes JU, Godoy-Navarrete J, Cabezas-Lucena AM, Estevez EC, Aguirre MA, González-Gay MA, Barbarroja N, Escudero-Contreras A, Lopez-Pedrera C. Personalized cardiovascular risk assessment in Rheumatoid Arthritis patients using circulating molecular profiles and their modulation by TNFi, IL6Ri, and JAKinibs. Biomed Pharmacother 2024; 173:116357. [PMID: 38479179 DOI: 10.1016/j.biopha.2024.116357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND & OBJECTIVES This study aimed to: 1) analyze the inflammatory profile of Rheumatoid Arthritis (RA) patients, identifying clinical phenotypes associated with cardiovascular (CV) risk; 2) evaluate biologic and targeted-synthetic disease-modifying antirheumatic drugs (b-DMARDs and ts-DMARDs': TNFi, IL6Ri, JAKinibs) effects; and 3) characterize molecular mechanisms in immune-cell activation and endothelial dysfunction. PATIENTS & METHODS A total of 387 RA patients and 45 healthy donors were recruited, forming three cohorts: i) 208 RA patients with established disease but without previous CV events; ii) RA-CVD: 96 RA patients with CV events, and iii) 83 RA patients treated with b-DMARDs/ts-DMARDs for 6 months. Serum inflammatory profiles (cytokines/chemokines/growth factors) and NETosis/oxidative stress-linked biomolecules were evaluated. Mechanistic in vitro studies were performed on monocytes, neutrophils and endothelial cells (EC). RESULTS In the first RA-cohort, unsupervised clustering unveiled three distinct groups: cluster 3 (C3) displayed the highest inflammatory profile, significant CV-risk score, and greater atheroma plaques prevalence. In contrast, cluster 1 (C1) exhibited the lowest inflammatory profile and CV risk score, while cluster 2 (C2) displayed an intermediate phenotype. Notably, 2nd cohort RA-CVD patients mirrored C3's inflammation. Treatment with b-DMARDs or ts-DMARDs effectively reduced disease-activity scores (DAS28) and restored normal biomolecules levels, controlling CV risk. In vitro, serum from C3-RA or RA-CVD patients increased neutrophils activity and CV-related protein levels in cultured monocytes and EC, which were partially prevented by pre-incubation with TNFi, IL6Ri, and JAKinibs. CONCLUSIONS Overall, analyzing circulating molecular profiles in RA patients holds potential for personalized clinical management, addressing CV risk and assisting healthcare professionals in tailoring treatment, ultimately improving outcomes.
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Affiliation(s)
- Laura Muñoz-Barrera
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Carlos Perez-Sanchez
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Rafaela Ortega-Castro
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Sagrario Corrales
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Maria Luque-Tevar
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Tomás Cerdó
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Ismael Sanchez-Pareja
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Pilar Font
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Raquel Lopez-Mejías
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, IDIVAL, Santander, Spain
| | - Jerusalem Calvo
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - M Carmen Abalos-Aguilera
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Desiree Ruiz-Vilchez
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Pedro Segui
- Radiology Service, Reina Sofia Hospital/Maimonides Institute for Research in Biomedicine of Cordoba/University of Cordoba, Spain
| | - Christian Merlo
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | | | | | | | | | | | | | | | | | | | | | - Eduardo Collantes Estevez
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Ma Angeles Aguirre
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | | | - Nuria Barbarroja
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Alejandro Escudero-Contreras
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain
| | - Chary Lopez-Pedrera
- Rheumatology service/Department of Medical and Surgical Sciences, Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC)/ Reina Sofia University Hospital/ University of Cordoba, Spain.
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Balazs I, Horvath A, Heschl B, Khalil M, Enzinger C, Stadlbauer V, Seifert-Held T. Anti-CD20 treatment and neutrophil function in central nervous system demyelinating diseases. J Neuroimmunol 2023; 381:578136. [PMID: 37364519 DOI: 10.1016/j.jneuroim.2023.578136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/29/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION A contribution of neutrophil granulocytes to the pathogenesis of multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) is recognized. Anti-CD20 treatments applied in these diseases are associated with infectious complications and neutropenia. No data is available about functional characteristics of neutrophils obtained from patients with anti-CD20 treatments. METHODS In neutrophils isolated from 13 patients with anti-CD20 treatment (9 MS, 4 NMOSD), 11 patients without anti-CD20 treatment (9 MS, 2 NMOSD) and 5 healthy controls, we analyzed chemotaxis, production of reactive oxygen species (ROS), phagocytosis, and formation of neutrophil extracellular traps (NET) in vitro. RESULTS Chemotaxis and ROS production were found unchanged between patients with and without anti-CD20 treatment or between patients and healthy controls. We found a higher proportion of non-phagocytosing cells in patients without anti-CD20 treatment compared to patients with anti-CD20 treatment and healthy controls. As compared to healthy controls, a higher proportion of neutrophils from patients without anti-CD20 treatments underwent NET formation, either unstimulated or stimulated with phorbol 12-myristate 3-acetate for 3 h. In about half of patients with anti-CD20 treatment (n = 7), NET formation of unstimulated neutrophils occurred already within 20 min of incubation. This was not observed in patients without anti-CD20 treatment and healthy controls. CONCLUSION Anti-CD20 treatment in MS and NMOSD patients does not alter chemotaxis and ROS production of neutrophils in vitro but might restore their impaired phagocytosis in these diseases. Our study reveals a predisposition to early NET formation in vitro of neutrophils obtained from patients with anti-CD20 treatment. This may contribute to associated risks of neutropenia and infections.
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Affiliation(s)
- Irina Balazs
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; Center for Biomarker Research in Medicine, Stiftingtalstrasse 5, 8010 Graz, Austria
| | - Angela Horvath
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; Center for Biomarker Research in Medicine, Stiftingtalstrasse 5, 8010 Graz, Austria
| | - Bettina Heschl
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
| | - Michael Khalil
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; Center for Biomarker Research in Medicine, Stiftingtalstrasse 5, 8010 Graz, Austria
| | - Thomas Seifert-Held
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria; Department of Neurology, Hospital Murtal, Gaaler Strasse 10, 8720 Knittelfeld, Austria.
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Choi D, Kim J, Yang JW, Kim JH, Park S, Shin JI. Dysregulated MicroRNAs in the Pathogenesis of Systemic Lupus Erythematosus: A Comprehensive Review. Int J Biol Sci 2023; 19:2495-2514. [PMID: 37215992 PMCID: PMC10197884 DOI: 10.7150/ijbs.74315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 12/11/2022] [Indexed: 05/24/2023] Open
Abstract
Systemic lupus erythematosus is a chronic autoimmune disease of which clinical presentation is vastly heterogeneous, ranging from mild skin rashes to severe renal diseases. Treatment goal of this illness is to minimize disease activity and prevent further organ damage. In recent years, much research has been done on the epigenetic aspects of SLE pathogenesis, for among the various factors known to contribute to the pathogenic process, epigenetic factors, especially microRNAs, bear the most therapeutic potential that can be altered unlike congenital genetic factors. This article reviews and updates what has been discovered so far about the pathogenesis of lupus, while focusing on the dysregulation of microRNAs in lupus patients in comparison to healthy controls along with the potentially pathogenic roles of the microRNAs commonly reported to be either upregulated or downregulated. Furthermore, this review includes microRNAs of which results are controversial, suggesting possible explanations for such discrepancies and directions for future research. Moreover, we aimed to emphasize the point that had been overlooked so far in studies regarding microRNA expression levels; that is, which specimen was used to assess the dysregulation of microRNAs. To our surprise, a vast number of studies have not considered this factor and have analyzed the potential role of microRNAs in general. Despite extensive investigations done on microRNA levels, their significance and potential role remain a mystery, which calls for further studies on this particular subject in regard of which specimen is used for assessment.
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Affiliation(s)
- Daeun Choi
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jimin Kim
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seoyeon Park
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
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Muacevic A, Adler JR, Gande A, Anusha M, Dar H, Baji DB. The Role of Biologics in Rheumatoid Arthritis: A Narrative Review. Cureus 2023; 15:e33293. [PMID: 36606106 PMCID: PMC9808655 DOI: 10.7759/cureus.33293] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/05/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory joint disease that can cause cartilage and bone damage as well as a disability. Various cytokines play an essential role in disease formation such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-1, IL-6, IL-17, and macrophages; osteoclast is also activated by the cytokines, which cause bone degradation. Early diagnosis is key to optimal therapeutic success, particularly in patients with well-characterized risk factors for poor outcomes such as high disease activity, presence of autoantibodies, and early joint damage. Treatment algorithms involve measuring disease activity with composite indices, applying a treatment-to-target strategy, and using conventional, biological, and new non-biological disease-modifying antirheumatic drugs. After the treatment target of stringent remission (or at least low disease activity) is maintained, dose reduction should be attempted. Although the prospects for most patients are now favorable, many still do not respond to current therapies. The biologics have changed the disease progression over the past few decades, such as TNF-alpha inhibitors (infliximab, etanercept, adalimumab, golimumab, certolizumab), IL-1 inhibitors (anakinra), IL-6 inhibitors (tocilizumab), CD20 inhibitors (rituximab), and cytotoxic T-lymphocyte associated antigen (CTLA)-4 inhibitors (abatacept). In treatment with biologics, only little is known if "biologic-free" remission is possible in patients with sustained remission following intensive biological therapy. Infliximab and etanercept, in the long run, develop the drug antibody. This article has reviewed the action of the cytokine on joints and biological drug's action in blocking the cytokine degradation effect, benefits of biologics, and adverse effects in the long and short term. They are also effective alone or in combination with other drugs.
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Mak A, Chan JKY. Endothelial function and endothelial progenitor cells in systemic lupus erythematosus. Nat Rev Rheumatol 2022; 18:286-300. [PMID: 35393604 DOI: 10.1038/s41584-022-00770-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 12/13/2022]
Abstract
The observations that traditional cardiovascular disease (CVD) risk factors fail to fully account for the excessive cardiovascular mortality in patients with systemic lupus erythematosus (SLE) compared with the general population have prompted in-depth investigations of non-traditional, SLE-related risk factors that contribute to cardiovascular complications in patients with SLE. Of the various perturbations of vascular physiology, endothelial dysfunction, which is believed to occur in the earliest step of atherosclerosis, has been extensively investigated for its contribution to CVD risk in SLE. Endothelial progenitor cells (EPCs), which play a crucial part in vascular repair, neovascularization and maintenance of endothelial function, are quantitatively and functionally reduced in patients with SLE. Yet, the lack of a unified definition of EPCs, standardization of the quantity and functional assessment of EPCs as well as endothelial function measurement pose challenges to the translation of endothelial function measurements and EPC levels into prognostic markers for CVD in patients with SLE. This Review discusses factors that contribute to CVD in SLE, with particular focus on how endothelial function and EPCs are evaluated currently, and how EPCs are quantitatively and functionally altered in patients with SLE. Potential strategies for the use of endothelial function measurements and EPC quantification as prognostic markers of CVD in patients with SLE, and the limitations of their prognostication potential, are also discussed.
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Affiliation(s)
- Anselm Mak
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Division of Rheumatology, University Medicine Cluster, National University Health System, Singapore, Singapore.
| | - Jerry Kok Yen Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Academic Clinical Programme in Obstetrics and Gynaecology, Duke-NUS Medical School, Singapore, Singapore.,Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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6
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Chang C, Xu L, Zhang R, Jin Y, Jiang P, Wei K, Xu L, Shi Y, Zhao J, Xiong M, Guo S, He D. MicroRNA-Mediated Epigenetic Regulation of Rheumatoid Arthritis Susceptibility and Pathogenesis. Front Immunol 2022; 13:838884. [PMID: 35401568 PMCID: PMC8987113 DOI: 10.3389/fimmu.2022.838884] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/02/2022] [Indexed: 12/19/2022] Open
Abstract
MicroRNAs (miRNAs) play crucial roles in regulating the transcriptome and development of rheumatoid arthritis (RA). Currently, a comprehensive map illustrating how miRNAs regulate transcripts, pathways, immune system differentiation, and their interactions with terminal cells such as fibroblast-like synoviocytes (FLS), immune-cells, osteoblasts, and osteoclasts are still laking. In this review, we summarize the roles of miRNAs in the susceptibility, pathogenesis, diagnosis, therapeutic intervention, and prognosis of RA. Numerous miRNAs are abnormally expressed in cells involved in RA and regulate target genes and pathways, including NF-κB, Fas-FasL, JAK-STAT, and mTOR pathways. We outline how functional genetic variants of miR-499 and miR-146a partly explain susceptibility to RA. By regulating gene expression, miRNAs affect T cell differentiation into diverse cell types, including Th17 and Treg cells, thus constituting promising gene therapy targets to modulate the immune system in RA. We summarize the diagnostic and prognostic potential of blood-circulating and cell-free miRNAs, highlighting the opportunity to combine these miRNAs with antibodies to cyclic citrullinated peptide (ACCP) to allow accurate diagnosis and prognosis, particularly for seronegative patients. Furthermore, we review the evidence implicating miRNAs as promising biomarkers of efficiency and response of, and resistance to, disease-modifying anti-rheumatic drugs and immunotherapy. Finally, we discuss the autotherapeutic effect of miRNA intervention as a step toward the development of miRNA-based anti-RA drugs. Collectively, the current evidence supports miRNAs as interesting targets to better understand the pathogenetic mechanisms of RA and design more efficient therapeutic interventions.
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Affiliation(s)
- Cen Chang
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lingxia Xu
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Runrun Zhang
- The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yehua Jin
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ping Jiang
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Kai Wei
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Linshuai Xu
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yiming Shi
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jianan Zhao
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Momiao Xiong
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center, Houston, TX, United States
| | - Shicheng Guo
- Center for Precision Medicine Research, Marshfield Clinic Research Institute, Marshfield, WI, United States
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
- *Correspondence: Shicheng Guo, ; Dongyi He,
| | - Dongyi He
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Arthritis Institute of Integrated Traditional and Western Medicine, Shanghai Chinese Medicine Research Institute, Shanghai, China
- *Correspondence: Shicheng Guo, ; Dongyi He,
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B cells as target for immunotherapy in rheumatic diseases - current status. Immunol Lett 2021; 236:12-19. [PMID: 34077805 DOI: 10.1016/j.imlet.2021.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/16/2021] [Accepted: 05/25/2021] [Indexed: 01/16/2023]
Abstract
This mini-review is a short overview of different therapeutical strategies targeting B cells in systemic autoimmune rheumatic diseases, mainly: rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and primary Sjogren Syndrome (pSS). Many strategies and their rationale are discussed in this review: B cells' depletion (anti-CD20, anti-CD22), long-lived plasma cells depletion (anti-CD19, anti-CD27, anti-CD38 and anti-CD138), changing activation of B cells (anti-BAFF) and inhibiting proteasomes in plasma cells (bortezomib). The past successful therapies and less successful are shown, and the possible reasons for failures are discussed.
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Zamora C, Cantó E, Vidal S. The Dual Role of Platelets in the Cardiovascular Risk of Chronic Inflammation. Front Immunol 2021; 12:625181. [PMID: 33868242 PMCID: PMC8046936 DOI: 10.3389/fimmu.2021.625181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/15/2021] [Indexed: 11/25/2022] Open
Abstract
Patients with chronic inflammatory diseases often exhibit cardiovascular risk. This risk is associated with the systemic inflammation that persists in these patients, causing a sustained endothelial activation. Different mechanisms have been considered responsible for this systemic inflammation, among which activated platelets have been regarded as a major player. However, in recent years, the role of platelets has become controversial. Not only can this subcellular component release pro- and anti-inflammatory mediators, but it can also bind to different subsets of circulating lymphocytes, monocytes and neutrophils modulating their function in either direction. How platelets exert this dual role is not yet fully understood.
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Affiliation(s)
- Carlos Zamora
- Inflammatory Diseases, Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Elisabet Cantó
- Inflammatory Diseases, Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Sílvia Vidal
- Inflammatory Diseases, Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
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Luque-Tévar M, Perez-Sanchez C, Patiño-Trives AM, Barbarroja N, Arias de la Rosa I, Abalos-Aguilera MC, Marin-Sanz JA, Ruiz-Vilchez D, Ortega-Castro R, Font P, Lopez-Medina C, Romero-Gomez M, Rodriguez-Escalera C, Perez-Venegas J, Ruiz-Montesinos MD, Dominguez C, Romero-Barco C, Fernandez-Nebro A, Mena-Vazquez N, Marenco JL, Uceda-Montañez J, Toledo-Coello MD, Aguirre MA, Escudero-Contreras A, Collantes-Estevez E, Lopez-Pedrera C. Integrative Clinical, Molecular, and Computational Analysis Identify Novel Biomarkers and Differential Profiles of Anti-TNF Response in Rheumatoid Arthritis. Front Immunol 2021; 12:631662. [PMID: 33833756 PMCID: PMC8022208 DOI: 10.3389/fimmu.2021.631662] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/15/2021] [Indexed: 12/29/2022] Open
Abstract
Background: This prospective multicenter study developed an integrative clinical and molecular longitudinal study in Rheumatoid Arthritis (RA) patients to explore changes in serologic parameters following anti-TNF therapy (TNF inhibitors, TNFi) and built on machine-learning algorithms aimed at the prediction of TNFi response, based on clinical and molecular profiles of RA patients. Methods: A total of 104 RA patients from two independent cohorts undergoing TNFi and 29 healthy donors (HD) were enrolled for the discovery and validation of prediction biomarkers. Serum samples were obtained at baseline and 6 months after treatment, and therapeutic efficacy was evaluated. Serum inflammatory profile, oxidative stress markers and NETosis-derived bioproducts were quantified and miRNomes were recognized by next-generation sequencing. Then, clinical and molecular changes induced by TNFi were delineated. Clinical and molecular signatures predictors of clinical response were assessed with supervised machine learning methods, using regularized logistic regressions. Results: Altered inflammatory, oxidative and NETosis-derived biomolecules were found in RA patients vs. HD, closely interconnected and associated with specific miRNA profiles. This altered molecular profile allowed the unsupervised division of three clusters of RA patients, showing distinctive clinical phenotypes, further linked to the TNFi effectiveness. Moreover, TNFi treatment reversed the molecular alterations in parallel to the clinical outcome. Machine-learning algorithms in the discovery cohort identified both, clinical and molecular signatures as potential predictors of response to TNFi treatment with high accuracy, which was further increased when both features were integrated in a mixed model (AUC: 0.91). These results were confirmed in the validation cohort. Conclusions: Our overall data suggest that: 1. RA patients undergoing anti-TNF-therapy conform distinctive clusters based on altered molecular profiles, which are directly linked to their clinical status at baseline. 2. Clinical effectiveness of anti-TNF therapy was divergent among these molecular clusters and associated with a specific modulation of the inflammatory response, the reestablishment of the altered oxidative status, the reduction of NETosis, and the reversion of related altered miRNAs. 3. The integrative analysis of the clinical and molecular profiles using machine learning allows the identification of novel signatures as potential predictors of therapeutic response to TNFi therapy.
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Affiliation(s)
- Maria Luque-Tévar
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Carlos Perez-Sanchez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Alejandra Mª Patiño-Trives
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Nuria Barbarroja
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Ivan Arias de la Rosa
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Mª Carmen Abalos-Aguilera
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Juan Antonio Marin-Sanz
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Desiree Ruiz-Vilchez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Rafaela Ortega-Castro
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Pilar Font
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Clementina Lopez-Medina
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain.,Hospital Universitario de Jaen, Jaén, Spain.,Hospital Universitario Virgen Macarena, Sevilla, Spain.,Hospital Clínico Universitario, Malaga, Spain.,Hospital Regional Universitario de Malaga, Malaga, Spain.,Hospital Universitario Virgen de Valme, Sevilla, Spain.,Hospital Universitario de Jerez de la Frontera, Cádiz, Spain
| | - Montserrat Romero-Gomez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | | | | | | | | | | | | | | | | | | | | | - M Angeles Aguirre
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Alejandro Escudero-Contreras
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Eduardo Collantes-Estevez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
| | - Chary Lopez-Pedrera
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Reina Sofia, Universidad de Cordoba, Córdoba, Spain
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10
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Mancardi D, Arrigo E, Cozzi M, Cecchi I, Radin M, Fenoglio R, Roccatello D, Sciascia S. Endothelial dysfunction and cardiovascular risk in lupus nephritis: New roles for old players? Eur J Clin Invest 2021; 51:e13441. [PMID: 33128260 DOI: 10.1111/eci.13441] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 12/19/2022]
Abstract
In systemic lupus erythematosus (SLE) patients, most of the clinical manifestation share a vascular component triggered by endothelial dysfunction. Endothelial cells (ECs) activation occurs both on the arterial and venous side, and the high vascular density of kidneys accounts for the detrimental outcomes of SLE through lupus nephritis (LN). Kidney damage, in turn, exerts a negative feedback on the cardiovascular (CV) system aggravating risk factors for CV diseases such as hypertension, stroke and coronary syndrome among others. Despite the intensive investigation on SLE and LN, the role of endothelial dysfunction, as well as the underlying mechanisms, remains to be fully understood, with no specifically targeted pharmacological treatment. It is not known, in fact, if the activation pathway(s) in venous ECs are similar to the one in arterial ECs and doubts persist on the shared manifestation of microcirculation compared to macrocirculation. In this work, we aim to review the recent literature about the role of endothelial activation and dysfunction in the development of CV complications in SLE and LN patients. We, therefore, focus on arteriovenous similarities and differences and on specific pathways of great vessels compared to capillaries. Critically summarising the available data is of pivotal importance for both basic researchers and clinicians in order to develop and test new pharmacological approaches in the treatment of basic components of SLE and LN.
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Affiliation(s)
- Daniele Mancardi
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Elisa Arrigo
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Martina Cozzi
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.,School of Specialization in Nephrology, University of Verona, Verona, Italy
| | - Irene Cecchi
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Massimo Radin
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Dario Roccatello
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Nephrology and Dialysis S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
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11
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Effects of Biological Therapies on Molecular Features of Rheumatoid Arthritis. Int J Mol Sci 2020; 21:ijms21239067. [PMID: 33260629 PMCID: PMC7731249 DOI: 10.3390/ijms21239067] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/16/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune and chronic inflammatory disease primarily affecting the joints, and closely related to specific autoantibodies that mostly target modified self-epitopes. Relevant findings in the field of RA pathogenesis have been described. In particular, new insights come from studies on synovial fibroblasts and cells belonging to the innate and adaptive immune system, which documented the aberrant production of inflammatory mediators, oxidative stress and NETosis, along with relevant alterations of the genome and on the regulatory epigenetic mechanisms. In recent years, the advances in the understanding of RA pathogenesis by identifying key cells and cytokines allowed the development of new targeted disease-modifying antirheumatic drugs (DMARDs). These drugs considerably improved treatment outcomes for the majority of patients. Moreover, numerous studies demonstrated that the pharmacological therapy with biologic DMARDs (bDMARDs) promotes, in parallel to their clinical efficacy, significant improvement in all these altered molecular mechanisms. Thus, continuous updating of the knowledge of molecular processes associated with the pathogenesis of RA, and on the specific effects of bDMARDs in the correction of their dysregulation, are essential in the early and correct approach to the treatment of this complex autoimmune disorder. The present review details basic mechanisms related to the physiopathology of RA, along with the core mechanisms of response to bDMARDs.
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12
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Al-Harbi NO, Nadeem A, Ahmad SF, AL-Ayadhi LY, Al-Harbi MM, As Sobeai HM, Ibrahim KE, Bakheet SA. Elevated expression of toll-like receptor 4 is associated with NADPH oxidase-induced oxidative stress in B cells of children with autism. Int Immunopharmacol 2020; 84:106555. [DOI: 10.1016/j.intimp.2020.106555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/21/2022]
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13
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Goldberg BS, Ackerman ME. Antibody-mediated complement activation in pathology and protection. Immunol Cell Biol 2020; 98:305-317. [PMID: 32142167 DOI: 10.1111/imcb.12324] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/27/2020] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
Abstract
Antibody-dependent complement activity is associated not only with autoimmune morbidity, but also with antitumor efficacy. In infectious disease, both recombinant monoclonal antibodies and polyclonal antibodies generated in natural adaptive responses can mediate complement activity to protective, therapeutic or disease-enhancing effect. Recent advances have contributed to the structural resolution of molecular complexes involved in antibody-mediated complement activation, defining the avid nature of participating interactions and pointing to how antibody isotype, subclass, hinge flexibility, glycosylation state, amino acid sequence and the contextual nature of the cognate antigen/epitope are all factors that can determine complement activity through impact on antibody multimerization and subsequent recruitment of complement component 1q. Beyond the efficiency of activation, complement activation products interact with various cell types that mediate immune adherence, trafficking, immune education and innate functions. Similarly, depending on the anatomical location and extent of activation, complement can support homeostatic restoration or be leveraged by pathogens or neoplasms to enhance infection or promote tumorigenic microenvironments, respectively. Advances in means to suppress complement activation by intravenous immunoglobulin (IVIG), IVIG mimetics and complement-intervening antibodies represent proven and promising exploratory therapeutic strategies, while antibody engineering has likewise offered frameworks to enhance, eliminate or isolate complement activation to interrogate in vivo mechanisms of action. Such strategies promise to support the optimization of antibody-based drugs that are able to tackle emerging and difficult-to-treat diseases by improving our understanding of the synergistic and antagonistic relationships between antibody mechanisms mediated by Fc receptors, direct binding and the products of complement activation.
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Affiliation(s)
| | - Margaret E Ackerman
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA.,Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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14
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Role of microRNAs in the Development of Cardiovascular Disease in Systemic Autoimmune Disorders. Int J Mol Sci 2020; 21:ijms21062012. [PMID: 32188016 PMCID: PMC7139533 DOI: 10.3390/ijms21062012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 12/11/2022] Open
Abstract
Rheumatoid Arthritis (RA), Systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) are the systemic autoimmune diseases (SADs) most associated with an increased risk of developing cardiovascular (CV) events. Cardiovascular disease (CVD) in SADs results from a complex interaction between traditional CV-risk factors, immune deregulation and disease activity. Oxidative stress, dyslipidemia, endothelial dysfunction, inflammatory/prothrombotic mediators (cytokines/chemokines, adipokines, proteases, adhesion-receptors, NETosis-derived-products, and intracellular-signaling molecules) have been implicated in these vascular pathologies. Genetic and genomic analyses further allowed the identification of signatures explaining the pro-atherothrombotic profiles in RA, SLE and APS. However, gene modulation has left significant gaps in our understanding of CV co-morbidities in SADs. MicroRNAs (miRNAs) are emerging as key post-transcriptional regulators of a suite of signaling pathways and pathophysiological effects. Abnormalities in high number of miRNA and their associated functions have been described in several SADs, suggesting their involvement in the development of atherosclerosis and thrombosis in the setting of RA, SLE and APS. This review focusses on recent insights into the potential role of miRNAs both, as clinical biomarkers of atherosclerosis and thrombosis in SADs, and as therapeutic targets in the regulation of the most influential processes that govern those disorders, highlighting the potential diagnostic and therapeutic properties of miRNAs in the management of CVD.
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15
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Pérez-Sánchez C, Cecchi I, Barbarroja N, Patiño-Trives AM, Luque-Tévar M, Pérez-Sánchez L, Ibáñez-Costa A, Arias de la Rosa I, Ortega R, Escudero A, Castro MC, Radin M, Roccatello D, Sciascia S, Aguirre MÁ, Collantes E, López-Pedrera C. Early restoration of immune and vascular phenotypes in systemic lupus erythematosus and rheumatoid arthritis patients after B cell depletion. J Cell Mol Med 2019; 23:6308-6318. [PMID: 31347786 PMCID: PMC6714224 DOI: 10.1111/jcmm.14517] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/06/2019] [Accepted: 06/04/2019] [Indexed: 12/22/2022] Open
Abstract
This translational multi‐centre study explored early changes in serologic variables following B lymphocyte depletion by rituximab (RTX) treatment in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) patients and investigated in vitro effects on the activity of other immune cells and the vascular endothelium. Eighty‐five SLE patients, seventy‐five RA patients and ninety healthy donors were enrolled. Two additional cohorts of selected SLE and RA patients were treated with RTX for 3 months. Changes in circulating levels of inflammatory mediators, oxidative stress markers and NETosis‐derived bioproducts were evaluated. Serum miRNomes were identified by next‐generation sequencing, and RTX‐induced changes were delineated. Mechanistic in vitro studies were performed to assess activity profiles. Altered inflammatory, oxidative and NETosis‐derived biomolecules were found in SLE and RA patients, closely interconnected and associated to specific miRNA profiles. RTX treatment reduced SLE and RA patients' disease activity, linked to a prominent alteration in those biomolecules and the reversal of altered regulating miRNAs. In vitro studies showed inhibition of NETosis and decline of pro‐inflammatory profiles of leucocytes and human umbilical vein endothelial cells (HUVECs) after B cell depletion. This study provides evidence supporting an early RTX‐induced re‐setting of the pro‐inflammatory status in SLE and RA, involving a re‐establishment of the homeostatic equilibrium in immune system and the vascular wall.
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Affiliation(s)
- Carlos Pérez-Sánchez
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Irene Cecchi
- Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Turin, Italy
| | - Nuria Barbarroja
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | | | - María Luque-Tévar
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Laura Pérez-Sánchez
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Alejandro Ibáñez-Costa
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Iván Arias de la Rosa
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Rafaela Ortega
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Alejandro Escudero
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - María Carmen Castro
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Massimo Radin
- Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Turin, Italy
| | - Dario Roccatello
- Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Turin, Italy
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Turin, Italy
| | - María Ángeles Aguirre
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Eduardo Collantes
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Chary López-Pedrera
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
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